KIDS Consideration Application

APPLICANT INFORMATION
Name of Child* Date of birth*
Sex* Male    Female    Phone*
Current address* City*
State* Favorite driver
Clothing sizes Shoe size
FAMILY INFORMATION
Parent Name* Parent Name*
Phone* E-mail*
Cell# City
ZIP Code Siblings
MEDICAL PROVIDER INFORMATION
Physician name    
Address City
State ZIP Code
Medicine(s) child takes
ANY LIMITATIONS OR FEARS
DOES THE CHILD HAVE ANY ISSUES WITH LOUD NOISE? CLOSE QUARTERS? SUDDEN MOVEMENTS?
 
TRANSPORTATION
Will you need assistance with transportation to and from scheduled events
     
DOES CHILD REQUIRE SPECIAL ACCOMODATIONS TO TRANSPORT? IF SO PLEASE EXPLAIN
 
HISTORY OF CHILDS MEDICAL SITUATION
Briefly explain child diagnosis from Medical Providers
COMMENTS/ A BRIEF STORY ABOUT YOUR CHILD
SIGNATURES
BY Virtual signing below you authorize an Speedway Angels representative to gather any information from medical physicians you provided within this form in consideration of an event approval. You also Understand that just by providing this information you are not Guaranteed anything from Speedway Angels Inc. more than consideration for programs they provide. If you are selected for an event a Representative will contact you by Phone we will never send you an email requesting any further information if you do receive an email that appears to be from Speedway Angels requesting any information from you do not respond and notify us right away of this activity.
Signature of applicant Date
Signature of spouse Date
  (only if for a joint membership)